Provider Demographics
NPI:1225077654
Name:MIRADI, MOHAMMED (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMED
Middle Name:
Last Name:MIRADI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MOHAMMED
Other - Middle Name:
Other - Last Name:MIRADI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 2353
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91943-2353
Mailing Address - Country:US
Mailing Address - Phone:619-644-1483
Mailing Address - Fax:619-644-8724
Practice Address - Street 1:5565 GROSSMONT CENTER DR
Practice Address - Street 2:STE 211
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3020
Practice Address - Country:US
Practice Address - Phone:619-644-1483
Practice Address - Fax:619-644-8724
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53125207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA531250Medicaid
CABM3903742OtherDEA #
CABM3903742OtherDEA #
CAA531250Medicaid